On November 7, 2014, the Burkina Faso Ministry

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1 an evidence-based advocacy initiative BURKINA FASO November 2015 Strategic Advocacy Leads Burkina Faso to Authorize Task-Sharing Pilot Project CASE STUDY On November 7, 2014, the Burkina Faso Ministry of Health authorized a family planning tasksharing pilot project in the Centre and Boucle du Mouhoun Regions of the country. Family planning stakeholders had pursued task-sharing policy changes for five years before Advance Family Planning (AFP) local partner Équilibres et Populations led focused advocacy to see it through alongside the national Technical Working Group for Reproductive Health (GT/SR). The pilot is the first step in providing the needed evidence for a national policy in line with World Health Organization task-sharing guidance and greater uptake of the new subcutaneous injectable, Sayana Press. The pilot will assess allowing certified nurses and auxiliary birth attendants to insert implants and intrauterine devices (IUDs) and permitting community health workers to provide first prescription of the pill and contraceptive injectables. Burkina Faso representatives took part in working sessions with Togo state health officers. advancefamilyplanning.org

2 Representatives from Burkina Faso went on a site visit to learn from a pilot program in Togo. What Can Task-Sharing Do for Family Planning? Task-sharing is the process of enabling lay and mid-level health care providers such as nurses, midwives, clinical officers, and community health workers to provide clinical tasks and procedures that would otherwise be restricted to higher level cadres. Burkina Faso s government long resisted the practice of task-sharing for contraceptive services for a variety of reasons: concerns regarding community health workers skill level; reluctance to delegate tasks to other categories of health staff; and a lack of flexibility in health policy protocols. Local family planning stakeholders, however, recognized that task-sharing s impact would be farreaching increasing access to and use of modern contraceptive methods in a country marked by a low contraceptive prevalence rate (15%) and high unmet need for family planning (24%). 1 Increased family planning access will help meet the objectives set in the Plan National de Relance de la Planification Familiale (National Family Planning Stimulus Plan ), the national plan to achieve a contraceptive prevalence rate of 25% by 2015, and increase coverage of basic health services among rural populations. This goal is reiterated in the country s Family Planning 2020 commitment and The Ouagadougou Declaration on Primary Health Care and Health Systems in Africa. While the pilot project may seem small focusing only on the Centre and Boucle de Mouhoun regions the two regions population constitute one-fifth of the country s total population. A successful pilot will provide strong evidence for establishing family planning task-sharing policies nationwide. 2 advancefamilyplanning.org

3 The Advocacy Turning Point Équilibres et Populations first identified task-sharing as an advocacy priority in They collaborated with the GT/SR, a coalition of more than 20 national and international nongovernmental organizations. The coalition faced resistance from the Ministry of Health and unreliable funding to undertake a task-sharing pilot. It took Équilibres et Populations adoption of the AFP approach in 2013 to establish a targeted, strategic approach to overcome the opposition. Brigitte Syan of Équilibres et Populations called it, a roadmap for advocacy. An AFP SMART facilitation led by regional partner Palladium (formerly Futures Group), service delivery organization Association Burkinabè pour le Bienêtre Familial (ABBEF), and Équilibres et Populations on September 17, 2013 identified and assessed the relevant decisionmakers, developed coherent messaging, and produced an advocacy workplan. Facilitation participants identified the Minister of Health as the decisionmaker, via the Director of Family Health. They agreed that Mr. Ouedraogo, the coordinator of Conseil Burkinabè pour les organization de Developpement Communautaire (BURCASO) in the GT/SR, would deliver the message, finding his 20 years of experience in family planning and influence as assets. Mr. Ouedraogo put forth the rationale that signing a memorandum of understanding (MOU) for a task-sharing pilot would increase the contraceptive prevalence rate, reduce unmet need for family planning, and contribute to the reduction of maternal and infant mortality, as supported by evidence from similar task-sharing programs in Togo and Ghana. In line with the multifaceted workplan, Équilibres et Populations and key family planning stakeholders from the GT/SR compiled the first iteration of an advocacy brief in June The brief cited a situational analysis on contraceptive security released by the Burkina Faso Ministry of Health in 2011, which included two key reasons for Burkinabe women s unmet need for family planning: 1. The low level of task-sharing, particularly at the health facility level, the first point of contact between the population and the health system 2. The limited role of certified birth attendants and auxiliary birth attendants, who usually manage family planning units. These health professionals are denied certain tasks that they could fulfill. 2 Members of the GT/SR then met with national authorities and civil society organizations to share information and come to a unified view on tasksharing. Global South-South Learning A critical step in the advocacy effort was a site visit to showcase a nearby pilot program. With support from AFP and technical assistance from Palladium, in collaboration with the Ministry of Health and other civil society organizations, Équilibres et Populations organized a site visit to Togo s AWARE II project. The program had produced positive findings: among its 435 trained community health workers, 432 learned to safely and correctly administer injectable contraception and became certified to begin delivery of services. With community health worker outreach, uptake of family planning services rapidly increased. Community health workers reached six times as many women in Haho district compared to health centers, and eight times as many in Blitta district. The implementation districts showed a 135% increase (from 20% to 47%) in the percentage of women using modern family planning methods between the baseline and end-of-project dates. The control districts showed no change in use (26%). 3 Representatives from the Burkinabe Directorate for Family Health and civil society visited Togo from March 3 to April 3, 2014 to review Togo s task-sharing experience. They met with state health officers in Haho and the Togo Ministry of Health. This trip helped to persuade the Burkinabe Director of Family Health to support the MOU for task-sharing in Burkina Faso. 3 advancefamilyplanning.org

4 Following the site visit, more than 25 stakeholders, including members of the GT/SR and the Directorate of Family Health, met five times to craft and validate the pilot project proposal and task-sharing protocol. They also revised the June 2013 advocacy brief and submitted all of the components to the Ministry of Health for approval. After several rounds of review, the Ministry s Directorate of Family Health submitted the document to the Minister of Health, who signed the MOU to authorize the task-sharing pilot on November 7, Lessons Learned Advocacy needs to be strategic and focused to be effective: In-country family planning stakeholders easily recognized the need for tasksharing, but did not overcome the obstacles until they mastered the SMART approach and applied focused advocacy tactics. Work closely with the government every step of the way: Collaborating closely with the government helped in finalizing the language of the MOU and pilot project plan. The coalition was better informed to build in ways to address the government s concerns and prevent obstacles from occurring later. Learn from those around you: Togo has a similarly designed health system to Burkina Faso and faces similar obstacles, which made drawing parallels simpler and more compelling. Next Steps The Government of Burkina Faso and various stakeholders are finalizing plans for the pilot project. Équilibres et Populations will coordinate the pilot with local service providers over a two-year period, which is expected to take place Service delivery organizations Marie Stopes International and ABBEF will provide contraceptive services in the pilot regions. 4 advancefamilyplanning.org

5 According to the MOU, Ministry of Health personnel will train health providers at community health centers to improve the quality of family planning service delivery. The certified nurses and auxiliary birth attendants at state health centers will learn how to insert implants and IUDs. Community health workers volunteers who support health authorities will provide first prescription of the pill and contraceptive injectables. In trials, Burkina Faso has administered 111,333 doses of Sayana Press, due mainly to rapid cascade training and widespread availability of the product at every level of the health system. Community health workers will be essential to scaling up access to this method. Équilibres et Populations will play an important role in documentation of the pilot to ensure that there is enough evidence to support future scale-up in two more regions, and potentially the entire country. References Burkina Faso Demographic and Health Survey. 2 Advocacy document for task sharing in family planning: authorizing certified nurses, certified birth attendants and trained auxiliary birth attendants to offer implants and IUDs. November Diagnostic analysis of the RESPOND project s sites. Community- Based Distribution of Hormonal Contraceptives in West Africa. USAID AWARE II June Advocacy document for task sharing in family planning: authorizing certified nurses, certified birth attendants and trained auxiliary birth attendants to offer implants and IUDs. November Cover photos: Patrick Masson, European Commission DG ECHO, Department of Foreign Affairs and Trade; Brigitte Syan, Équilibres et Populations; page 2: Brigitte Syan, Équilibres et Populations; page 4: Eric Montfort; page 6: Jason Hall. Members of the Technical Group on Reproductive Health (GT/SR): Équilibres et Populations Association Burkinabè pour le Bien-être Familial (ABBEF) Marie Stopes International Burkina Faso Family Care International Conseil Burkinabè pour les organization de Developpement Communautaire (BURCASO) AES Burkina Africare Association Songui Manegré/Aide au Developpement Endogène EngenderHealth, projet RESPOND/B Fondation Rama GASCODE Initiative Privee et Communautaire de Lutte contre le VIH / SIDA Jhpiego Médecins du Monde France Médecins du Monde Espagne Medicus Mundi Mouvement français pour le Planning familial Population Council PROMACO Réseau Africain Jeunesse Santé et Développement au Burkina Faso SOS /Jeunesse et Défis SOS Sante et Developpement Union des Réligieux et Coutumiers du Burkina Faso pour la Santé et le Développement 5 advancefamilyplanning.org

6 Acknowledgments Équilibres et Populations thanks the Ministry of Health authorities who signed the memorandum of understanding and authorized the testing of the task-sharing in the regions of Centre and Boucle du Mouhoun, as well as members of the GT/SR for their support in the preparations and implementation of the advocacy. Équilibres et Populations thanks AFP for its technical and financial support, which allowed them to succeed in advocacy with national and local authorities. Équilibres et Populations is particularly thankful to their support team (Alison Bodenheimer, AFP and Dr. Modibo Maiga, Palladium and AFP) who have consistently helped them to overcome the difficulties they have encountered along the way. AFP is supported by the Bill & Melinda Gates Foundation, the David & Lucile Packard Foundation, and The William and Flora Hewlett Foundation. Advance Family Planning Bill & Melinda Gates Institute for Population and Reproductive Health Johns Hopkins Bloomberg School of Public Health 615 N. Wolfe Street, Ste. W4503 Baltimore, MD Tel: +1 (410) Équilibres et Populations PO Box: 09 BP 903 Ouagadougou 09 Burkina Faso advancefamilyplanning.org

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